By Carin Lefkowitz on 22.03.2017 9:46 am

Recently I was invited to attend a lecture by LTC (Ret.) Dave Grossman titled “The Psychological Effect of Combat.” I knew of LTC Grossman because so many of my military clients raved about his books, On Killing and On Combat. I was intrigued to see him speak, but was also quite skeptical about his message and expected to disagree with him at every turn. He’s a keynote speaker at NRA events and made several hunting analogies, while I am a vegetarian, who is proud to not own any leather goods. He has a black belt in martial arts and is the director of the Killology Research Group, while I get queasy when I see UFC matches. To use his own terms, he’s a proud “Sheep Dog” and I am definitely a docile grazing “sheep.”

Suffice it to say that I didn’t expect to relate to the 3 ½ hour lecture, but I was pleasantly surprised to find that a large part of his effort to empower military and law enforcement is to keep them psychologically healthy. Our views on stigma, PTSD, and sleep were often similar. However, whereas I express my viewpoints using very scientific terms (mostly to justify my very expensive degrees), Grossman drive his points home with accessible and entertaining analogies that engaged the audience of military and law enforcement personnel. I’ll be weaving some of his analogies into my clinical practice and share them with you here with his permission.

On the stress response: In my workshops, I describe the normal stress response in humans and how the primitive amygdala temporarily shuts down the rational prefrontal cortex. Audiences (clinicians) usually like this discussion and want to share it with patients so that patients can better understand their reactions. Grossman has a more colorful way to describe this phenomenon. He describes the midbrain as “the puppy brain” because it includes all of the drives and functions that are shared across species. He described the prefrontal cortex as “the leash,” controlling those human qualities that allow for advanced problem solving, inhibition, and morality. The audience laughed when he said that if someone is in fight or flight mode, they’re reacting from their puppy brain. If you try to reason or argue with them in that state, you’re essentially “arguing with your dog…how productive is that?”

Grossman further explained the commonality of the post-trauma stress response. He described how most people will experience symptoms of re-experiencing and hyperarousal following a traumatic event and noted the importance of not avoiding those symptoms. Making reference again to the midbrain and fight/flight response, he says “You’re not losing your mind. It’s just the puppy coming to visit.” Instead he encourages individuals to use “the leash,” to accept and manage intrusive memories, remind themselves that remembering is not the same as reliving, and to not rely on avoidance as a coping mechanism. He gave an especially powerful example of this in regard to his son, who served nine combat tours in the Air Force. At home, Grossman and his son talk openly about post-trauma reactions; the family acknowledges common symptoms without shame and even chuckle together when a picture of Yoda triggers a visit from “the puppy.”

On the stigma of mental health conditions and treatment: We all agree that there can be a stigma attached to mental health disorders and treatment, especially for military-connected patients. I frequently compare physical conditions to psychological conditions with patients and try to normalize mental health treatment. So I wasn’t surprised when Grossman essentially asked (paraphrased here):

“If you woke up with a cramp in your leg every night and went to work exhausted every day as a result, how long would it take you to make a doctor’s appointment? 3 days? A week? A month? Why do you wait longer when what’s waking you up every night is your heart beating out of your chest or a nightmare?”

What did surprise me and made me laugh out loud was his approach to reducing the stigma of mental health treatment. He gave the example of a soldier who is diagnosed with PTSD, receives effective treatment and is cleared to return to duty. He says a soldier in that example essentially receives discharge paperwork from their doctor stating “You’re sane!” He follows up with, “How many people can say they have a note from a doctor certifying that they’re sane?! You’re doing better than most!”

On sleep: Some of my favorite points from Grossman’s lecture were on the importance of sleep. It’s generally understood that sleep deprivation is a significant problem in this country, especially for military populations. With a focus on completing missions, the need for sleep gets minimized and equated with weakness. Grossman argues that good (quantity AND quality) sleep is integral for productivity and performance. He destroys any logic connecting equating sleep need with weakness (“Depriving yourself of sleep is not tough; any girl at a slumber party can do it!”) and reminds the audience that sleep should be enjoyed, not avoided (“Sleep is a little vacation at the end of every day.”). In discussing the role that sleep hygiene plays in good quality sleep, Grossman takes particular umbrage with the snooze button. I can attest that patients with poor sleep often do not want to give up that snooze feature. There’s something about “going back to sleep for a few more minutes” that is so alluring, even when I explain in painstaking detail how the effect on quality of sleep is not worth the extra few minutes of dozing. Once again, Grossman offers a more convincing argument: “Waking up in the morning is the worst part of the day. The snooze button just forces you to live the worst part of your day over and over again!” It's hard to argue with that logic.

On resilience and recovery: One of Grossman’s take home messages is that individuals can and do recover from whatever psychological effect combat has had upon them. He notes that while combat experiences may permanently change a person’s outlook or priorities, they do not have to be disabling. He makes the analogy of weighing the effect that combat has in pounds. At the height of PTSD, an individual might have an extra 500 pounds of pressure on them, effectively making them psychologically obese and limiting their functioning. But a posttraumatic stress reaction is less intense for many, adding only an extra 50 or even 5 psychological pounds. A reaction of this intensity will affect functioning, but in a far less dramatic way and perhaps even in a positive way (i.e., posttraumatic growth). The individual who has been coping with 500 pounds of PTSD CAN “lose weight” with effective treatment.

The best parts of Grossman’s workshop were, ultimately, not his funny anecdotes and analogies. The best part was recognizing that there are similarities in the goals of clinicians and combat trainers. It’s clear to me that Grossman’s goal is to train military and law enforcement personnel to be effective warriors in a world that he sees as increasingly dangerous and volatile. But his message is that one must be healthy to be effective. And this is how leadership, clinicians, and warriors can work together toward the common goal of a healthy force.

Many thanks to LTC Grossman for graciously allowing CDP to share his ideas with our readers. For excerpts of his books On Killing and On Combat, visit www.killology.com.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Carin Lefkowitz, Psy.D., is a clinical psychologist and Cognitive Behavioral Therapy Trainer at the Center for Deployment Psychology.